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The purpose of this study was to determine whether the results of resection of the distal ulna differed depending upon the underlying aetiology of the condition. Patients with rheumatoid arthritis were compared with patients with post-traumatic wrist complaints. Fifty resections in 40 patients (eight male, 32 female) were assessed with respect to pain, range of motion, and grip strength. Of the 23 rheumatoid wrists, 86% were pain-free following surgery; however, only 36% of the patients in the trauma group reported pain relief postoperatively. Pain relief in post-traumatic patients was more predictable when distal radioulnar joint arthrosis was identified as the sole cause of wrist pain.

Twenty-two patients with normal x-ray films who required decompression of the sixth dorsal compartment for tenovaginitis were identified. Retrospective review of charts and operative reports were possible in 18, and 12 returned for reexamination at 43 months (average). All had preoperative tenderness along the extensor carpi ulnaris tendon increased by resisted ulnar deviation and forced radial deviation; all had had transient relief with injection of local anesthetic. Nonsurgical treatments were used for an average of 6 months prior to surgery. Thirteen patients related symptom onset to a single traumatic event, usually a forced twisting. Surgical release was achieved by simply incising the retinaculum with no attempt at repair. Postoperatively patients were followed for an average of 10 months to recovery; grip improved by 28%, to equal 79% of the unaffected side. Two patients required secondary Darrach resections for improvement. At late reexamination, grip strength averaged 94% of the unaffected side; there were no signs of distal ulna or extensor carpi ulnaris tendon instability. In our experience, surgical decompression for resistant sixth dorsal tenovaginitis does not destabilize the distal ulna or the extensor carpi ulnaris tendon.

This experimental study was conducted to determine the best scaphoid position, measured as the radioscaphoid (RS) angle for optimum wrist motion after scapho-trapezio-trapezoid (STT) and scaphocapitate (SC) fusion and to assess the implications of radial styloidectomy on motion after STT fusion. STT and SC fusions were simulated in six fresh cadaver hands with the scaphoid in horizontal, neutral, and vertical positions with respect to the long axis of the radius seen on lateral x-rays. RS angle and wrist motion were measured on x-ray films before and after each simulated arthrodesis. Radial deviation and wrist extension increased as the RS angle increased (i.e., increased as the scaphoid became more nearly vertical). Ulnar deviation and flexion decreased as the scaphoid became more nearly horizontal. We found no statistically significant differences in RS angle between SST and SC fusions with respect to ulnar deviation, flexion, or extension. However, radial deviation was more sensitive to RS angle after STT fusion than after SC fusion, but the differences were not statistically significant. The ideal radioscaphoid angle (range) for maximal wrist motion when STT fusion is performed is 41 to 60 degrees; when SC fusion is performed, it is 30 to 57 degrees. Motion is not improved by radial styloidectomy after simulated STT fusion.

Twenty-three patients with zone V flexor tendon lacerations rehabilitated by the Kleinert protocol were studied at an average of 46 months after trauma. Hand function was subjectively normal in only eight. Of fourteen patients who were employed at the time of injury, eight returned to their original occupations. Eight others were working at other jobs, and we considered six more capable of employment. Only one had a poor functional result that precluded occupational use of the hand. Pinch/grip strengths recovered to 85%/79% of the uninvolved side. Independent flexor digitorum superficialis/flexor digitorum profundus action was present in only seven patients. Sixteen regained full digital flexion. Extension loss averaged 25% at the wrist and 10% in each digit. As assessed by static two-point discrimination, sensibility was poor after associated median and ulnar nerve transections; this did not preclude good objective functional results. Complications included two tendon ruptures, proximal interphalangeal hyperextension in the presence of an unrepaired flexor digitorum superficialis, and limited motion in two patients after poor compliance in therapy. Tenolysis was needed in 4 of the 23. We now use a modified Duran technique for noncompliant patients and in those who are unable to extend their PIP joints because of weak intrinsic muscles.

We reexamined 17 patients at 16 to 57 months (average, 23.4 months) after scaphocapitate arthrodesis. Surgery was performed for treatment of rotary scaphoid instability, isolated arthrosis, resistant scaphoid nonunion, and prevention of carpal collapse in Kienböck's disease. Scaphocapitate fusion with autogenous bone grafting was used to bridge carpal spaces. Two patients had nonunion of the scaphocapitate arthrodesis, which required reoperation. Seven patients experience persistent pain with heavy use; of these, two changed occupations and one remains disabled. Compared with the nonoperated side, scaphocapitate fusion reduced wrist extension an average of 28 degrees, flexion 40 degrees, radial deviation 14 degrees, and ulnar deviation 14 degrees. The greatest loss was of radial deviation. Static grip reached a average of 74% of the nonoperated side. Dynamic power regained 73%, and dynamic endurance measured 105% of the nonoperated side. Motion peaked after six months on average, and then reached a plateau. Static strength peaked at 11 months and then stabilized.

Seven different types of intercarpal arthrodeses that are commonly used in clinical practice were simulated in wrists of cadavera by drilling two nonparallel Kirschner wires across the involved joint that was to be fused. The changes in radial deviation, ulnar deviation, dorsiflexion, and palmar flexion, and the arc of motion in two planes (radial plus ulnar deviation and dorsiflexion plus palmar flexion) were compared with control values for each specimen and with each of the other arthrodeses. All of the data were analyzed by calculating the mean and standard error of the changes in these motions of the wrist as compared with the control values for each wrist. The statistical significance of the changes was derived by the t test. For values of t greater than 2.262, the observed mean reductions in the motions were statistically significant (p = 0.05) in all wrists except those that had simulated arthrodesis of the lunate-triquetrum or the capitate-hamate joint. No statistically significant differences were noted between the effects of arthrodesis of the scaphoid-trapezium-trapezoid, scaphoid-capitate, and scaphoid-lunate joints on the motions of the wrist. All arthrodeses except those of the lunate-triquetrum and the capitate-hamate joint produced a statistically significant decrease in the total arc of motion; arthrodesis of the capitate-lunate joint produced the most statistically significant decrease in total arc of motion. In our opinion, the results of the study suggest that there is limited justification for arthrodesis of the capitate-hamate joint.(ABSTRACT TRUNCATED AT 250 WORDS)

The trapeziometacarpal joint is often affected by arthritis and treated by surgical methods. The significant forces to which this joint is subjected challenge even the most sturdy prosthetic materials. Short-term complications of arthroplasty are caused by inadequate bony resection and instability. Serious long-term problems results from implant wear and the host tissues' response to the implant. Although silicone elastomer prostheses are generally well tolerated, wear-induced microparticles (15 micron or less) incite an intense inflammatory and destructive synovial response. This "silicone synovitis" typically presents more than two years after arthroplasty and is characterized by pain, swelling, and lytic lesions visible on roentgenogram. The silicone microparticles are generated by cyclic physiologic bearing, shear, and compression forces for which these implants have not been tested. The destructive synovitis is arrested by synovectomy, implant removal, and curettage of the lytic defects. Functional salvage requires conversion to resection arthroplasty or arthrodesis. Patients with silicone implant arthroplasty must be followed indefinitely, at frequent intervals, by clinical examination and roentgenograms. Overall, however, experience indicates that resection arthroplasty is the most predictable and functional procedure for the nonrheumatoid basal thumb joint.